Teething, Sugar, and Bullies – PediaCast 011

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  • Teething
  • Sugar and Hyperactivity
  • Bullies
  • Runner's Knee



Announcer 1: This is PediaCast, episode 11 for October 2nd 2006.


Announcer 2: Hello moms, dads, grandmoms, grandpas, aunts, uncles and anyone else who looks after kids. Welcome to this week's episode of PediaCast, a pediatric podcast for parents. And now, direct from BirdHouse Studios, here is your host, Dr. Mike Patrick Jr.

Dr. Mike Patrick: Hello, everyone and welcome to this week's edition of PediaCast, a pediatric podcast for parents. This is Dr. Mike Patrick Jr. coming to you from BirdHouse Studios and I'd like to welcome everyone to the program.

This week on the show we're talking about Infant Teething, Sugar and Hyperactivity in Toddlers (Is it truth or is it a myth?), also we'll look at Bullies at School and Runner's Knee. Now, you noticed we only have four topics this week instead of our usual seven of eight and that's because we're experimenting with shorter episodes that come out more frequently.

We'll still address topics ranging from infants to teens with each episode, but only one from each age range rather than two. I think it so make it easier for parents to find the topics that interest them. Keep in mind many of our topics are pertinent to multiple age ranges and we'll continue to include those as well.

And speaking of topics, don't forget if you have a topic you would like us to address on PediaCast, you can submit your request on the contact page of our website. Simply go to pediascribe.com/podcast and click on the Contact link. You can also reach us by emailing podcast@pediascribe.com or by calling our voice line at 347-404-KIDS, that's 347-404-K-I-D-S.

Now if you like PediaCast you may want to check out our blog at pediascribe.com. We also feature a weekly newsletter called PediAlert, which will keep you up-to-date with the happenings at PediaScribe and PediaCast, as well as breaking news from sources you trust like the American Academy of Pediatrics and the Centers for Disease Control. To sign up for our news letter, simply go to our blog or the podcast page and click on the PediAlert link.


Now before we get started I want to give you an update on the spinach story that we did last week. The FDA reports this, "Spinach in stores is now safe to eat. The E. coli-tainted spinach came from Natural Selection Foods, LLC of San Juan Bautista, California."

The E. coli outbreak ended up involving about 187 cases of the illness. There were 97 hospitalizations, 29 cases of hemolytic uremic syndrome or HUS, which we talked about on our last episode, and there was one confirmed death and two other deaths are still under investigation.

The offending organism was the deadly O157:H7 strain of the bacteria. For more information about this form of E. coli, hemolytic uremic syndrome and the spinach outbreak, listen to episode 10 of PediaCast.

Now before we also get started, I want to tell you a little story for my practice that happened this last week, which really illustrates the frustration in dealing with the state-supported insurance system. I saw a young man who suffers from migraine headaches and his insurance is our state's Medicaid. Now, Medicaid subcontracts out with an out of state pharmacy management company and I wanted to treat this young man with a medicine called Midrin. I thought that would be the best medicine for him given his particular clinical situation.

So I wrote the prescription for Midrin and his mom took it to the pharmacy. The pharmacist submitted it to our state's Medicaid system in the computer and the prescription was denied with a note from the pharmacy management company saying that Midrin requires a preauthorization.

Now, I vaguely recalled it from past experience that I'd had to send in preauthorization forms for Medicaid in the past. So I did that and the next day the pharmacy management company denied the preauthorization and they wanted me to substitute the Midrin for something on their "approved list".

Well, the only reasonable alternative that was on Medicaid's list was a drug called Imitrex. And Imitrex is a fine drug for migraines but a bottle of 30 Midrin costs about $20 wholesale compared to over $200 for the same number of Imitrex tablets.

So we called the pharmacy management company to complain, well short story we're on hold, passing the phone off from one staff member in our office to another because we're still seeing patients and taking phone messages from parents for nearly an hour we're on hold. And the pharmacy management lady was very apologetic and she was too nice to really get angry with because you could tell it wasn't her fault, she was getting as much of a runaround as we were.

She talked to this person and that person and then checked this policy and that procedure and bottom line they won't pay for the Midrin and want me to prescribe the Imitrex instead. Then she asks me if the patient is on state Medicaid and I'd say that he is and she replies, "Well, he doesn't have to pay for the Imitrex. His prescriptions are free."

Hello? Anybody in there? Somebody pays for the medicine! I pay it. You pay it. I tell her this and she says, "Yeah, I guess you're right about that, but they still won't approve it." Got to love the "they", they are the ones you can never talk to.

Well our other option was to bypass the pharmacy management company and go directly to the state, but then we'll be on hold all day or all week and not just an hour. So I give a big sigh and give in. I tell my nurse to go ahead the young man's pharmacist and order up the Imitrex, so she does and the pharmacist says, "Oh, I resubmitted it first thing this morning and this time it went through. The patient picked up the Midrin an hour ago."

Ahhh… See? Even doctors have moments in a day when you just want to scream! And some folks are advocating a state-run health system for everybody? Yeah, that's a good idea. Oh, brother!


All right, before we get started with our first topic, let me remind you that the purpose of PediaCast is to discuss topics of interest to parents and families. When we talk about medical issue it's in a generic sense. We do not address specific problems in specific children because there's no substitution for a face-to-face interview and hands-on physical examination in determining a diagnosis and formulating a treatment plan. Therefore, if you're concerned with your child's health you should call his or her doctor to discuss the problem.

The views and advice expressed here on PediaCast are my own and should not be considered the standard of care because medical variations which taken to account individual circumstances may be appropriate.

OK. Let's move on to our first topic of this episode and that's going to be teething. Now, definition of teething, teething is basically the normal process of new teeth working their way through the gums. The first tooth may appear any time between three months and one year of age and they tend to follow a family pattern.

So if a lot of the kids in your family are getting teeth when they're between three and maybe six months of age that's probably when your child's going to get their first tooth as well; or if it's closer to a year of age or maybe even a titch after a year then that runs in some families as well.

There's really no good way to predict when a tooth is coming. I tell people it's coming when you see it break through and sometimes that happens fast and sometimes the tooth seems to come right just beneath the gum surface and you can really feel it in there then it sort of stalls and just stays in that same location for quite some time.

You have to be patient, you know I've been practicing pediatrics for more than 10 years and in that time I've only seen one child who failed to have teeth before the age of about 18-24 months and that child had a rare connective tissue disorder. So most of the dentists get concerned if they haven't had a tooth or up by the time that they're somewhere between 18 and 24 months. But most babies are going to do it way before then.


In terms of symptoms, for most babies teething is painless. They can have some increased saliva production, which leads to drooling, and although lots of babies drool long before their first tooth is up so it's up for debate whether teething actually causes the drooling or maybe perhaps they're just happening at the same time.

Babies also tend to have increased desire to chew on things, that's common during teething as well. And for some babies teething may cause mild gum discomfort. The degree of discomfort really is going to vary from child to child. In general, it's not severe pain. So if your baby seems to be in severe pain or can't sleep because of pain or what you perceive is pain you shouldn't blame teething on that. You definitely want to take the baby and to see the doctor.

Many unrelated illnesses and symptoms are blamed on teething and this is because teething is a continuous process for a lot of kids between six months of age and about two years of age. Now prior to six months most babies are pretty healthy, thanks to mom's immunity because her antibodies cross through the placenta and they're basically protecting the baby with mom's immune system up until about age six months or so.

And then at around six months of age, which is the same time most babies start teething, mom's immunity is wearing out and kids are much more susceptible to illness. So the fevers that babies get around this time are caused by infections and that they are just happening to occur at the same time, but teething is not actually causing the fevers, infections are. And again, they're just usually happening at about the same time so that's how that relationship came to be thought of.

Also, teething does not cause diarrhea or diaper rash either, it does not do that. Oh and then one other thing, too, teething will not lead to ear infections. Ear infections are caused by viruses and bacteria, not the eruption of teeth. And again, that's the sort of thing when kids around this age that's the time when they get a lot of ear infections and that just happens to be the same time that they're teething, but the two things are not related.


Now in terms of teething order, any pattern is possible but the most usual sequence is going to be first the lower incisors, which are the middle teeth on the bottom, and then after that the upper incisors. First molars are next and then canine teeth or the eye teeth and then a second molar is after that. But then again, really, any combination or order of those things is certainly possible.

Now what do you do for teething? Well if you think your child is uncomfortable because of teething, a two-minute gum massage with your finger or a piece of ice is a good idea. Wash your hands first. Teething rings and other such devices are fine, they help the chewing desire that goes along with teething, but you want to chill those in the fridge first because kids will like the cold feeling on the gums, but you don't want to put them in the freezer. Ice on the gum for too long can cause frostbite and actually increase pain. They can also freeze their hand as well as messing with the things that they put in their mouth.

So if you're going to use ice you should actually hold it in your own finger and not apply it for more than two minutes and just make sure you're moving it around a lot during that two-minute period. Also don't use popsicles or other frozen items. You also want to avoid hard foods that can result in choking like raw carrots. Teething biscuits are fine for older babies but you got to be aware, they're really, really messy.

If your child still seems to be in pain from teething, you can try some infant Tylenol, but make sure you call your doctor if you're unsure of the dose that you should use. If the Tylenol doesn't work or you need to use Tylenol more than a couple of days make sure you call your doctor. Also call your doctor if your child has a fever greater than 100.5 degrees rectally because again, teething does not cause fever.

Fever and pain indicate something other than teething so you have to call your doctor. Also teething gels, such as Anbesol and Orajel, they generally provide little benefit. If you want to try one use the baby formulation, apply it sparingly and no more than a couple of times a day.

Babies actually can overdose on those teething gels resulting in some problems so be careful with them.



OK. Sugar and hyperactivity. It's a popular belief that sugar ingestion makes kids hyperactive. Now where did this idea originate? And does it really happen or is it simply a myth? If it does happen, what's the science behind the reason? And if it's not true, how do we know?

Well, this idea actually came from Dr. Benjamin Feingold, M.D., this was back in the late 60s, early 70s. And this idea that food was linked to behavior was originally published in his Feingold Diet in 1973 and it advocated the removal of food colorings and artificial flavorings as a result for treating hyperactivity disorder.

The Feingold Diet did not specifically call for decreased sugar in a diet but one thing led to another and popular culture began adding to the list of things to avoid and one of the early additions was refined sugar. Then in 1978, a study published in the Food and Cosmetic Toxicology Journal (Yes, there really is such a thing!) found that hyperactive kids who were given a large sugar load actually often times had a resulting drop in their blood sugar.

Now why would that be? Well the thought was that a large glucose load leads to an overactive insulin response by the body. So the pancreas releases a big load of insulin in response to the increased blood sugar caused from the sugar ingestion. And this insulin overcorrection would lead to low blood sugar.

Now low blood sugar can cause irritability, increased emotions and grumpiness, but hyperactivity usually is not seen. Still, word got out that sugar ingestion causes behavioral changes because of the result in low blood sugar. So the original idea that kids shouldn't have too much sugar was sort of reinforced.

Keep in mind, in this particular study, the sugar load came in the form of a glucose tolerance test. Now anyone who has ever had one of those knows you drink a large amount of just sickening sweet drink. So remember this kids had a huge sugar load, much higher than a kid would get from a couple of cookies or a candy bar.


Now let's fast forward to a couple of decades. In 1995, a study was published in JAMA, that's the Journal of the American Medical Association, and basically in this study, large numbers of kids were divided into two groups. One group had a snack with a huge sugar load and the other basically had a placebo, so it did not have sugar in the snack.

Parents and researchers did not know which children were in which group. So the researchers and parents then rated the kids with regard to their behavior for several hours after the snack and there was no difference in the behavioral scales for the two groups. So it didn't seem to make much of a difference whether the kids really did have a snack that had a lot of sugar in it versus one that had no sugar in it at all.

Now another recent study looked at a large number of kids whose parents reported them as having a sugar sensitivity. Parents of both groups were told their children were going to be given a high sugar snack and they were to rate their children's behavior afterward.

But the parents didn't know is that only half the kids were really given a sugar snack and the other half's snack did not really contain any sugar at all. Both groups of parents reported an increase in hyperactive behavior following ingestion of the snack making the argument that parent's perceptions and expectations might be coming into play.

Now having said that, if a certain food really seems to adversely affect your child's behavior, avoid it. What I wouldn't is avoid an entire food group all together. Remember everything in moderation is a good rule of thumb. And if you're considering a radical change in your child's diet to affect their behavior be sure to discuss the plan with your child's doctor so you can proceed in a safe manner that does not decrease quantities of important nutrients.

You know today's kids would certainly benefit from less sugar. Less sugar, less fat, less calories. But my advice is not aimed at combating hyperactivity; it's to decrease the explosion of childhood obesity we're seeing these days.



OK. On to a our discussion about bullies. With the new school year well under way I thought it'd be a good idea to talk about bullies. We all come across bullies everyday even as adults, we come across them at our places of work, when we're driving, sometimes even at church. They make us feel uncomfortable even as adults.

Well when kids have to deal with bullies at school it can cause lots of stress and discomfort. Sometimes signs of physical illness result. And there's something else to consider, the bullies themselves, often these kids are bullied at home and are simply reinforcing practicing behavior that they've learned from their family.

Do we simply discount them or do we try to help them as well as help the victims of bullying? I think we should help both. But before we talk about how to do that, let's take a look at some statistics. Research surveys suggest that in any given year 30%-60% of all-American school children report being bullied on a regular basis. One recent survey reported 58% of school children claimed to have stayed home from school at least one day during a school year to avoid a bully.

Now as adults when we see a bully doing his or her thing we have a tendency to want to right or wrong. We think back to our own childhood or more recent times and recall how we felt when a bully intimidated us. And because of this past experience it's natural to want to intervene, to stop the bully's behavior, to teach the bully a lesson or to punish the behavior.

But keep in mind when you do this from the perspective of the bully you are the bully and you're a bigger and more powerful person picking on someone smaller and weaker. You're teaching the bully basically that it's OK to exert power over another person just because you can.

Keep in mind I'm not talking about a person of authority over the bully, so I'm not talking about a bully's parent or teacher. They have a right to extend power over the bully because of their position. And teaching children to respect and obey those in positions of authority is fine. I'm talking about the incidental adult witnessing a bullying event or the parent of the child who's being bullied. If the parent of the child being bullied bullies the bully we're simply perpetuating a vicious cycle and not really going to change anything other than to encourage the bully to do his or her thing out of sight of grownups or with a different child.


So how do we handle the bully? Well if you witness a bullying and the bully is physically hurting the victim you know you should intervene. However, don't use violence to do this, unless you want the police at your door a few hours later. Usually, your presence is enough to stop the physical violence and send the bully moving on.

At this point, you should try to contact someone who has authority over the bully to address the situation. This includes parents, teachers and other school officials. Unfortunately, talking to a bully's parent may not get you very far because all too often they are bullies themselves. Talking to school officials will probably get you further in really correcting the situation.

And there are many things schools can do to stop bullying. Find out what your school is doing by attending school board meetings and asking questions. Here are some of the things that schools can do as outlined by the American School Counselor Association – they can develop an anti-bullying social norms that are early in elementary school. They can basically not accept any kind of bullying behavior right from kindergarten and make it know to kids that that's not going to be tolerated in the school.

They can actually form a zero tolerance for bullying behavior with consequences of bullying clearly understood by all students and then following through on this punishment for clear cases of bullying behavior.

And then third is to institute a school violence prevention program. Now school violence prevention programs are something that schools are starting to put into place with more frequency. And these are programs that help aggressive students develop better relations with others and they appear to be effective at reducing violent behaviors in schools. These programs teach kids to be better listeners and to think about the feelings of others. They learn to work cooperatively with others and how to be assertive without being aggressive. Of course these are things parents are supposed to be teaching their children at home, but again, many of these kids come from homes where parent teaching is in short supply, if you know what I mean.


Now while these programs are ideally begun at a young age studies have shown them to be effective at all grade levels from elementary school through high school. Research has been done which involved randomly assigned problem kids to intervention and control groups at all age levels. So any of these problem kids some of them were assigned to a particular program that is aimed at preventing violence and the others were just basically sent to the study hall.

Nearly 3,000 students were included in this report which looked at the behavior of bullies immediately after participating in intervention programs as well as 12 months later. There was a significant reduction in aggressive behavior at all grade levels for kids who participated in real intervention groups compared to the kids assigned to control groups. And this difference was seen immediately following participation and continued to hold through even 12 months later. Some of the intervention groups taught kids how to be assertive without being aggressive and sought to improve relationship and social skills. These types of programs were more effective than ones that simply taught skills of non-response to provocative situations.

So these kinds of programs can make a difference in the lives of bullies because they provide life lessons these kids aren't learning at home. If your school doesn't offer these types of programs, attend school board meetings and make yourself heard. It'll improve the quality of education kids get and ultimately improve the community in which you live.

Now what can parents do? Well you should be teaching the same skills in your home. Often it's helpful to teach kids techniques for getting the bully on his or her side as well. So teaching assertiveness skills, humor and conflict management are all beneficial.

You want to help your child build a social safety network and encourage them not to allow themselves to get into a situation where a bully could hurt them without witnesses. They should travel with friends and make use of the buddy system at all times.

Also, you want to be careful not to bully your children with intimidation and physical aggression. Otherwise, you're just teaching your children it's OK to behave that way.

You can find more information on bullying at the National Youth Violence Prevention Resource Center (Boy! That's a mouthful.) and we'll have a link to their bullying information in the Show Notes. Another great resource aimed at children dealing with the bully at school is Bullies2Buddies, which instructs children on helpful techniques for getting bullies on their side and you can visit their site at www.bullies2buddies.com. That's B-U-L-L-I-E-S, the number 2, then buddies, B-U-D-D-I-E-S, .com. And again, we'll put a link in the Show Notes.

Dealing with bullies is one of those things you wish your kids didn't have to encounter at school. But let's face it even as adults we come across bullies on a regular basis and if we teach our kids the proper way to approach them at a young age they'll be grateful for the lessons they carry on into their adult lives.



OK And we're going to wind down episode 11 with a little segment on runner's knee. Now runner's knee is known in the medical world as "patellofemoral syndrome" and I know that sounds like a big word, but let's just break it down. The patella is the knee cap and femur is the thigh bone. So patellofemoral syndrome involves pain where the kneecap and the thigh bone meet.

This is a common sports-related overused injury in young athletes and it occurs more often in girls than it does in boys with an estimated 30%-40% of all teenage female athletes suffering from it at some point in their athletic career. Runner's knee appears to be caused by improper tracking of the kneecap in the patellofemoral groove, which is just the bones' usual location, it's a little groove there underneath the kneecap, that's where it's supposed to be and the thigh bone and the kneecap basically rests in this grove, that's where it's supposed to be.

Now in patellofemoral syndrome the kneecap is malaligned with this groove that's not in quite the right place and that causes pain and inflammation. And this type of runner's knee occurs five times more often in girls than in boys. In some other cases the problem's a bit different. If athletic conditioning produces significantly stronger hamstrings compared to the quadriceps then the kneecap can become compressed and that also results in pain and inflammation and that type of runner's knee is most often seen in teenage boys.

Because of the malalignment or compression of the kneecap the knees point slightly toward each other and the feet compensate by turning slightly outward. And then athletic overuse with those positional problems of the knees and feet result in chronic knee inflammation and the pain and sometimes there's even swelling around the kneecap as well, but that's not always the case.

Diagnosis starts with a positive history of athletic overuse, especially in teenage girls, and your doctor will perform a complete musculous skeletal exam noting the positional abnormalities of the knees and the feet. And the malalignment is associated with the laxity of the kneecap's ligaments, meaning your doctor can easily move the kneecap around during the exam.

Also when you extend the knee the doctor will note the kneecap tracks in a J pattern, that's pretty common with this and helps with the diagnosis. Now other problems can present with chronic knee pain, such as Osgood-Schlatter disease and some serious hip disorders as well. And we're going to discuss those in further detail in upcoming episodes of PediaCast.

So it's important not to diagnose this yourself at home. If you have chronic knee pain be sure to see your doctor so he or she can establish the correct diagnosis and rule out more serious problems.


So what do you do for runner's knee? Well once it's diagnosed the treatment involves rest and rehabilitation. Strengthening the quadriceps and increased flexibility of the knee joint are also useful. Your doctor may have a strength and flexibility plan for you or he may refer you out to a sports oriented physical therapist.

The rehabilitation for runner's knee is often a slow process really with lots of ups and downs. You have good days and bad days, good weeks and bad weeks and sometimes good months and bad months and you'll likely understand exactly what they mean when they say "no pain, no gain" with sports. But don't give up. Find the sports you enjoy that your knees will tolerate and do your best to stay active.

Now that combined with a balance diet and moderated quantity of food will help keep you fit and healthy.



Well that wraps up this week's episode of PediaCast. Thanks to Nick and Katy for providing our program's introduction. Also thanks to Catherine for helping out as my sound engineer. Don't forget if you have a topic you would like us to address on PediaCast, you can submit your request on the Contact page of our website. Simply go to pediascribe.com/podcast and click on the Contact link.

You can also reach us by emailing podcast@pediascribe.com or by calling our voice line at 347-404-KIDS. That's 347-404-K-I-D-S.

If you like PediaCast be sure to tell your friends, relatives and neighbors about us and if you have the time a quick word of encouragement over the iTunes store would be appreciated as well. The PediaScribe blog is waiting for you at pediascribe.com and if you haven't signed up for our PediAlert newsletter yet be sure to stop by the website at pediascribe.com/podcast and click on the PediAlert link.

So until next week, this is Dr. Mike Patrick Jr. saying stay smart, stay healthy and stay involved with your kids. So long everybody!


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